Form Table of Changes

Table of Changes - FORM

Form I-612, Application for Waiver of the Foreign Residence Requirement (Under Section 212(e) of the INA, as Amended)

OMB Number 1615-0030

12/03/2014

Reason for Revision: To incorporate 2 column/standard formatting for data collections and full page format for the instructions, I-94 information, and new signature sections.

Current Location	Current Text	Proposed Text
Page 1,	Alien Registration Number (A-Number), (if known) 1.Name (Last in CAPS) First Middle la. If you are a married woman, give your maiden name. lb. Include all other previously used names, including aliases, tribal names, etc. 2. Mailing Address (Apt. No.) (Number and Street) (Town or City) (State or Province) (Country) (Zip Code, if in US) Present or last U.S. residence (Number and Street) (City) (State) (Zip Code) 3. Date of Birth (mm/ddlyyyy) Place of Birth (City/Town, Province/State/ Country) Country of Citizenship/Nationality Country of Last Foreign Residence (City/Town, Province/State/Country) Telephone Number (With area code) E-Mail Address, if any	[Page 1] Type or print in black ink. Part 1. Information About You 1. Alien Registration Number (A-Number) (if any) 2. USCIS ELIS Account Number (if any) Your Full Name 3.a. Family Name (Last Name) 3.b. First Name (Given Name) 3.c. Middle Name Provide other names you have used, including maiden name, aliases and tribal names. 4.a. Family Name (Last Name) 4.b. First Name (Given Name) 4.c. Middle Name 5.a. Family Name (Last Name) 5.b. First Name (Given Name) 5.c. Middle Name Your Mailing Address 6.a. Street Number and Name 6.b. Apt./Ste./Flr. [Fillable Field] 6.c. City or Town 6.d. State 6.e. ZIP Code 6.f. Province 6.g. Postal Code 6.h. Country If you are currently living abroad, enter your last address in the United States. 7.a. Street Number and Name 7.b. Apt./Ste./Flr. [Fillable Field] 7.c. City or Town 7.d. State 7.e. ZIP Code Other Information 8. Date of Birth (mm/dd/yyyy) 9. City/Town/Village of Birth 10. Country of Birth 11. Country of Citizenship or Nationality [Page 2] 12. Country of Last Foreign Residence [Deleted] [Deleted]
Page 1,	4. I believe I am subject to the foreign residence requirement because: (Check appropriate box(es)) A. I participated in an exchange program that was financed by an agency of the U.S. Government or the government of the country of my nationality or last foreign residence for the purpose of promoting international educational and cultural exchange. B. An agency of the Government of the United States or the government of the country of my nationality or last foreign residence gave me a grant (such as a Fullbright grant), stipend or allowance for the purpose of participation in an exchange program. Name of U.S. Government agency or foreign country: C. I became an exchange visitor after the U.S. Secretary of State designated the country of my nationality or last foreign residence as clearly requiring the services of persons with my specialized knowledge or skill. D. I entered the United States as, or my status was changed to, an exchange visitor on or after January 10, 1977, to participate in graduate medical education or training.	[Page 2] Part 2. Reason for Foreign Residence Requirement I believe I am subject to the foreign residence requirement because (Select all applicable boxes): 1. I participated in an exchange program that was financed by an agency of the U.S. Government or the government of my country of citizenship or nationality or last foreign residence, for the purpose of promoting international education and cultural exchange. 2. An agency of the U.S. Government or the government of my country of citizenship or nationality or last foreign residence gave me a grant (such as a Fulbright grant), stipend, or allowance for the purpose of participating in an exchange program. Enter the name of the U.S. Government agency or country of nationality or last foreign residence [Fillable Field]. 3. I became an exchange visitor after the U.S. Secretary of State designated my country of citizenship or nationality or last foreign residence as clearly requiring the services of persons with my specialized knowledge or skill. 4. I entered the United States as, or my status was changed to, an exchange visitor on or after January 10, 1977, to participate in graduate medical education or training.
Page 1-2	5. I am applying for a waiver of the foreign residence requirement on the ground that: (Check appropriate box(es)) A. My departure from the United States would impose exceptional hardship on my U.S. citizen or lawful permanent resident spouse or child. B. I cannot return to the country of my nationality or last foreign residence because I would be subject to persecution on account of race, religion, or political opinion. IMPORTANT ADVISORY: If you have checked "A" under Number 5, you must attach to this application a statement dated and signed by you giving a detailed explanation of the basis for your belief that compliance by you with the 2-year foreign residence requirement of Section 212(e) of the Immigration and Nationality Act would impose exceptional hardship on your spouse or child who is a citizen of the United States or a lawful permanent resident thereof. Without such statement your application is incomplete. You must include in the statement all pertinent information concerning the income and savings of yourself and your spouse. Attach also documentary evidence as may be available to support the allegations of hardship. If you have checked "B" under Number 5, you must attach a statement dated and signed by you setting forth in detail the reason(s) you believe why you cannot return to the country of your nationality or last foreign residence because you would be subject to persecution on account of race, religion, or political opinion. Attach also documentary evidence as may be available to support the allegations of persecution. [Page 2] 13.  Name of Spouse Date and Country of Birth Nationality/Citizenship Country of Last Foreign Residence 14.  Names of Children Date and Country of Birth Nationality/Citizenship Country of Last Foreign Residence Names of Children Date and Country of Birth Nationality/Citizenship Country of Last Foreign Residence	[Page 2] Part 3. Reason for Application for Waiver of Foreign Residence Requirement I am applying for a waiver of the foreign residence requirement because (Select only one box): 1. My departure from the United States would impose exceptional hardship on my U.S. citizen or lawful permanent resident spouse or child. 2. I cannot return to my country of citizenship or nationality or last foreign residence because I would be subjected to persecution on account of race, religion, or political opinion. IMPORTANT ADVISORY: If you selected Item Number 1. in Part 3., you must attach a statement giving a detailed explanation why you believe that your compliance with the two-year foreign residence requirement of section 212(e) of the Immigration and Nationality Act (INA) would impose exceptional hardship on your U.S. citizen or lawful permanent resident spouse or child. You must also sign and date the statement. If you do not include this statement, your application is incomplete. In your statement, you must also include all pertinent financial information regarding your and your spouse’s income and savings. You must also attach any available evidence that supports your claims of hardship. If you selected Item Number 2. in Part 3., you must attach a statement that details the reasons why you believe you cannot return to your country of citizenship or nationality or last foreign residence because you would be subject to persecution on account of race, religion, or political opinion. You must also sign and date the statement and attach any available evidence that supports your claims of persecution. (See the General Requirements section of the Instructions for additional information.) List all J-2 dependents that are included in this application. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. Information About Spouse 3.a. Family Name (Last Name) 3.b. First Name (Given Name) 3.c. Middle Name 3.d. Date of Birth (mm/dd/yyyy) 3.e. Country of Birth 3.f. Country of Citizenship or Nationality 3.g. Country of Last Foreign Residence [Page 3] Information About Children If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 4.a. Family Name (Last Name) 4.b. First Name (Given Name) 4.c. Middle Name 4.d. Date of Birth (mm/dd/yyyy) 4.e. Country of Birth 4.f. Country of Citizenship or Nationality 4.g. Country of Last Foreign Residence 5.a. Family Name (Last Name) 5.b. First Name (Given Name) 5.c. Middle Name 5.d. Date of Birth (mm/dd/yyyy) 5.e. Country of Birth 5.f. Country of Citizenship or Nationality 5.g. Country of Last Foreign Residence 6.a. Family Name (Last Name) 6.b. First Name (Given Name) 6.c. Middle Name 6.d. Date of Birth (mm/dd/yyyy) 6.e. Country of Birth 6.f. Country of Citizenship or Nationality 6.g. Country of Last Foreign Residence
Page 1-2	[Page 2] 7. List all program numbers and names of all program sponsors. 8. Major field of activity (Check one) (1) Agriculture D (7) Natural and Physical Sciences (2) Business Administration (3) Education (4) Engineering (5) Humanities (6) Medicine (7) Natural and Physical Sciences (8) Social Sciences (9) Other 9. Occupation 10. Date and port of last arrival in the United States as a participant in a designated exchange program. 11. If you are now abroad, give date of departure from United States. 12. Number of prior marriages of applicant If married, number of prior marriages of applicant's spouse [Page 1] 6. If married, check appropriate box(es): (See Page 2 of the Instructions) A. My spouse is included in this application. B. My spouse is filing a separate application for a waiver. [Page 2] 15. If you checked "A" under Number 5 on Page 1 of this form, provide the following information concerning your spouse or one of your children who is a citizen of the United States and who you believe would suffer exceptional hardship if you resided outside the United States for 2 years following your departure from this country. Name of U.S. citizen spouse or child: U.S. citizenship of spouse or child was acquired through (Check one) Birth in the United States Naturalization Parent(s) If the U.S. citizenship of spouse or child was acquired through naturalization, give the following: Number of Naturalization Certificate Date of Naturalization Place of Naturalization If the U.S. citizenship of spouse or child was acquired through parent(s), has the spouse or child obtained a Certificate of Citizenship? If yes, give the number of the certificate If no, submit evidence in accordance with Page 2 of the Instructions. 16. If you checked "A" under Number 5 on Page 1 of this form and you do not have a spouse or child who is a citizen of the United States, provide the following information concerning your spouse or one of your children who is a lawful permanent resident of the United States and who you believe would suffer exceptional hardship if you resided outside the United States for 2 years following your departure from this country. Name of lawful resident alien spouse or child: Alien Registration Number (A-Number): Date, place, and means of admission for lawful permanent residence:	[Page 3] Part 4. Additional Information About You If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 1. List all exchange program numbers and names or all exchange program sponsors. Major field of activity (Select only one box): 2.a. Agriculture 2.b. Business Administration 2.c. Education 2.d. Engineering 2.e. Humanities 2.f. Medicine 2.g. Natural and Physical Sciences 2.h. Social Sciences 2.i. Other 3. Occupation 4. Date of last entry into the United States as a participant in a designated exchange program. (mm/dd/yyyy) 5. Port-of-Entry (POE) of last arrival in the United States as a participant in a designated exchange program. City or Town State 6. If you are now abroad, give the date of your most recent departure from the United States (mm/dd/yyyy) [Deleted] [Page 4] If you are married, select only one box. 7.a. My spouse is included in this application. 7.b. My spouse is filing a separate application for a waiver of the foreign residence requirement. 7.c. My spouse is not included in this application. If you selected Item Number 1. in Part 3., provide the following information about your U.S. citizen spouse or child who you believe would suffer exceptional hardship if you resided outside of the United States for two years following your departure from the United States. Name of the U.S. citizen spouse or child 8.a. Family Name (Last Name) 8.b. First Name (Given Name) 8.c. Middle Name U.S. citizenship of spouse or child was acquired through (Select only one box): 9.a. Birth in the United States 9.b. Naturalization 9.c. Parents If your spouse or child acquired U.S. citizenship through naturalization, provide the following information for each naturalized individual: 10.a. Number of Naturalization Certificate 10.b. Date of Naturalization (mm/dd/yyyy) 10. c. Place of Naturalization City or Town State If your spouse or child acquired U.S. citizenship through parents, provide the following information for your spouse and each child who obtained citizenship through parents: 11.a. Has your spouse or child obtained a Certificate of Citizenship? 11.b. If you answered “Yes” to Item Number 11.a., type or print the number of , the certificate. Spouse Certificate of Citizenship Number Date of Issuance (mm/dd/yyyy) Child Certificate of Citizenship Number Date of Issuance (mm/dd/yyyy) 11.c. If you answered “No” to Item Number 11.a., submit evidence in accordance with the “General Requirements” section of the Instructions. If you selected Item Number 1. in Part 3., and you do not have a U.S. citizen spouse or child but you have a spouse or child who is a lawful permanent resident (LPR) of the United States, please provide the following information about your LPR spouse or child who you believe would suffer exceptional hardship if you resided outside of the United States for two years following your departure from the United States. Name of the lawful permanent resident spouse or child: 12.a. Family Name (Last Name) 12.b. First Name (Given Name) 12.c. Middle Name Other Information About Lawful Permanent Spouse or Child 13. A-Number (if any) 14. Date of adjustment to lawful permanent resident status (mm/dd/yyyy) 15. Location where your spouse or child became a lawful permanent resident City or Town State 16. Basis (preference category) for adjusting to lawful permanent resident status (for example, F-2A, Spouse or unmarried child of an LPR; F-2B, Unmarried sons or daughters of an LPR)
Page 2,	17. APPLICANT'S CERTIFICATION: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. Signature of applicant Executed on (Date) Place	[Page 5] Part 5. Applicant’s Statement, Contact Information, USCIS ASC Acknowledgement, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-612 Instructions before completing this part. Applicant's Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. I can read and understand English, and have read and understand every question and instruction on this application, as well as my answer to every question. I have read and understand the Acknowledgement of Appointment at USCIS Application Support Center. 1.b. The interpreter named in Part 6. has read to me every question and instruction on this application, as well as my answer to each question, in [Fillable Field], a language in which I am fluent. I understand every question and instruction on this application as translated to me by my interpreter, and have provided complete, true, and correct responses in the language indicated above. The interpreter named in Part 6. has also read the Acknowledgement of Appointment at USCIS Application Support Center to me, in the language in which I am fluent, and I understand this Application Support Center (ASC) Acknowledgement as read to me by my interpreter. 2. I have requested the services of and consented to [Fillable Field], who is/is not an attorney or accredited representative, preparing this application for me. This person who assisted me in preparing my application has reviewed the Acknowledgement of Appointment at USCIS Application Support Center with me, and I understand the ASC Acknowledgement. Applicant’s Contact Information [sub header] 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone 5. Applicant’s Email Address (if any) Acknowledgement of Appointment at USCIS Application Support Center I, [Auto-populate Field with Applicant’s Full Name], understand that the purpose of a USCIS ASC appointment is for me to provide my fingerprints, photograph, and/or signature and to re-affirm that all of the information in my application is complete, true, and correct and was provided by me. I understand that I will sign my name to the following declaration which USCIS will display to me at the time I provide my fingerprints, photograph, and/or signature during my ASC appointment: By signing here, I declare under penalty of perjury that I have reviewed and understand my application as identified by the receipt number displayed on the screen above, and all supporting documents, applications, petitions, or requests filed with my application, petition, or request that I (or my attorney or accredited representative) filed with USCIS, and that all of the information in these materials is complete, true, and correct. I also understand that when I sign my name, provide my fingerprints, and am photographed at the USCIS ASC, I will be re-affirming that I willingly submit this application; I have reviewed the contents of this application; all of the information in my application were provided by me and all supporting documents submitted with my application were provided by me and are complete, true, and correct; and if I was assisted in completing this application, the person assisting me also reviewed this Acknowledgement of Appointment at USCIS Application Support Center with me. Applicant’s Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. I certify, under penalty of perjury, that the information in my application and any document submitted with my application were provided by me and are complete, true, and correct. Applicant’s Signature 6.a. Applicant’s Signature 6.b. Date of Signature (mm/dd/yyyy) [Deleted] NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the instructions, USCIS may deny your application.
New		[Page 6] Part 6. Interpreter’s Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter’s Full Name [sub header] 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter’s Mailing Address [sub header] 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable Field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Interpreter’s Contact Information [sub header] 4. Interpreter's Daytime Telephone Number 5. Interpreter’s Email Address (if any) Interpreter’s Certification [sub header] I certify that: I am fluent in English and [Fillable Field], which is the same language provided in Part 5., Item Number 1.b. I have read to this applicant every question and instruction on this application, as well as the answer to every question, in the language provided in Part 5., Item Number 1.b.; I have also read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant in the same language provided in Part 5., Item Number 1.b. The applicant has informed me that he or she understands every instruction and question on the application, as well as the answer to every question, and the applicant verified the accuracy of every answer; and The applicant has also informed me that he or she understands the ASC Acknowledgement and that by appearing for a USCIS ASC biometric services appointment and providing his or her fingerprints, photograph, and/or signature, he or she is re-affirming that the contents of this application and all supporting documentation are complete, true, and correct. Interpreter’s Signature [sub header] 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy)
Page 2,	SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT: Address of person preparing form, if other than applicant Telephone Number E-Mail Address I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge: Signature Date Occupation	[Page 6] Part 7. Contact Information, Statement, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant Provide the following information about the preparer. Preparer’s Full Name 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable Field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country [Page 7] Preparer’s Contact Information 4. Preparer’s Daytime Telephone Number 5. Preparer’s Fax Number 6. Preparer’s Email Address (if any) Preparer’s Statement 7.a. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant’s consent. 7.b. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer’s Certification By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this application on behalf of, at the request of, and with the express consent of the applicant. I completed this application based only on responses the applicant provided to me. After completing the application, I reviewed it and all of the applicant’s responses with the applicant, who agreed with every answer on the application. If the applicant supplied additional information concerning a question on the application, I recorded it on the application. I have also read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant and the applicant has informed me that he or she understands the ASC Acknowledgement. Preparer’s Signature 8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy) [Deleted]
New		[Page 8] Part 8. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Include your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1.a. Family Name (Last Name) [Auto-populated field] 1.b. Given Name (First Name) [Auto-populated field] 1.c. Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable Field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable Field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable Field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable Field] 7.a. Applicant’s Signature 7.b. Date of Signature (mm/dd/yyyy)

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